REPORT

Pushed to the Limit and Beyond A year into the largest ever Ebola outbreak Content

This year thousands of health workers have risked their lives 5 Sounding the alarm to support patients and help control the Ebola outbreak, 8 Global coalition of while facing stigma and fear in their own communities. The inaction vulnerability of medical staff to Ebola is a double tragedy – the virus takes the lives of the very people meant to tackle it. Nearly 13 Last hope to control 500 healthcare workers have died of Ebola in , and the outbreak to date. 16 Doctors without a cure… but with care This report is dedicated to them and to our 14 MSF colleagues who have lost their lives in Guinea, Sierra Leone and Liberia 20 Looking to the future during this epidemic. They are sorely missed and our deepest 22 Map of the region sympathies remain with their families and friends.

8,351 people admitted into MSF Ebola Since the start of the outbreak in West Africa, MSF has set In 2014, MSF spent €59,054,680 on its Ebola up 15 Ebola management and transit* centres management centres. response

* Transit centres are short-stay centres for people to await The remaining €789,668 was spent responding in blood test results. If the test comes back negative, they , Nigeria and Senegal will be discharged. If positive, they will be transferred to an Ebola management centre.

COVER PICTURE An MSF health worker in protective clothing carries a child suspected of having Ebola in the MSF treatment centre in Monrovia, Liberia on 5 October 2014.

© John Moore/Getty Images |2 Introduction

We are now a year into the deadliest Ebola outbreak the world decline in cases, yet the country will has ever seen, with at least 24,000 people infected and more than remain at risk while Ebola lives on in 10,000 deaths. Ebola has destroyed lives and families, left deep neighbouring Guinea and Sierra Leone. scars, and ripped at the social and economic fabric of Guinea, Liberia and Sierra Leone. A significant challenge remains ahead of us. To declare an end to the out- The virus cut a vast swathe through the months were wasted and lives were break, we must identify every last case, three countries, in a cross-border geo- lost. No one knows the true number of requiring a level of meticulous preci- graphical spread never seen before. deaths the epidemic will have ultimately sion that is practically unique in med- Fear and panic set in, the sick and their caused: the resulting collapse of health ical humanitarian interventions in the families were desperate, and national services means that untreated , field. There is no room for mistakes or health workers and MSF teams were complicated deliveries and car crashes complacency; the number of new cases overwhelmed and exhausted. Medical will have multiplied the direct Ebola weekly is still higher than in any pre- workers are not trained to deal with at deaths many times over. vious outbreak. Success in reducing the least 50 percent of their patients dying number of cases in one location can be from a disease for which no treatments A year later, the atmosphere of fear and swiftly ruined by an unexpected flare-up exist. Nevertheless, the world at first the level of misinformation still circu- in an unforeseen area. ignored the calls for help and then lating continue to hamper the ability belatedly decided to act. Meanwhile, to halt the virus. In Sierra Leone, hot- Many questions, few simple spots persist, while in Guinea health answers MSF Ebola management centre, Kailahun, workers come under violent attack due A year into the outbreak, many ques- Sierra Leone. A medical team gets ready to to ongoing mistrust and fear. Encour- tions abound. How did the epidemic enter the high-risk zone. agingly, Liberia has seen the sharpest spiral so spectacularly out of control? © Sylvain Cherkaoui/Cosmos Sylvain ©

3| Why was the world so slow to wake up to its severity and respond? Was it due to fear, lack of political will, lack of exper- A SADLY UNIQUE YEAR tise, or a perfect storm of all three? Did While MSF has helped to control Ebola outbreaks in nine MSF make the right choices? How could MSF have done more and saved more countries over the past 20 years, the epidemic that has raged in lives? What have we learned from this west Africa proved uniquely catastrophic. In the past year, MSF outbreak and what must be done differ- has been pushed to the limits and beyond, launching a response ently in future? There are many ques- marked by many firsts for the organisation, many of them tragic tions and few simple answers. beyond words. MSF teams are still absorbed in tack- The first time we: ling the ongoing outbreak, and it is dif- ficult to draw definitive conclusions ∙ Lost so many patients to Ebola, ∙ Shipped in and set up incinerators whilst lacking the necessary distance 2,547 of our patients have died, a to cremate bodies, as happened for a thorough critical review. Here we catastrophically high number that in Monrovia when the national put forward initial reflections on the shocked MSF teams – even in most burial teams could not cope with the past year, describing key moments and warzones, losing so many patients number of dead. challenges from the perspective of MSF in such a short time is unheard of. staff. More in-depth reviews will cer- ∙ Distributed approximately 70,000 tainly follow. ∙ Had MSF colleagues fall sick with home protection and disinfection Ebola, 28 of whom became infected kits for 600,000 people in Monrovia. This paper is based on interviews with and 14 tragically passed away. dozens of our staff who give a snap- ∙ Distributed antimalarial drugs shot of the reality for MSF over the past ∙ Turned Ebola patients away, as to more than 650,000 people in year, both on the ground and in head- happened at our overwhelmed facil- Monrovia and 1.8 million people in quarters. We have been tested, pushed ity in Monrovia. Freetown. beyond our limits, and made our share of mistakes. ∙ Responded to viral haemorrhagic ∙ Constructed a specialised materni- fever on such a large scale in ty unit to care for pregnant women What also clearly emerges is that no multiple countries simultaneously with Ebola. one was prepared for the nightmarish – Ebola in Guinea, Sierra Leone, spread and magnitude of this epi- Liberia, Nigeria, Mali, Senegal, in ∙ Embarked on MSF’s largest knowl- demic. The Ebola outbreak proved to addition to an unrelated Ebola edge transfer effort, with more be an exceptional event that exposed outbreak in Democratic Republic of than 800 MSF staff trained on safe the reality of how inefficient and slow Congo and Marburg in Uganda. Ebola management in headquarters, health and aid systems are to respond as well as 250 people from other to emergencies. ‘Business as usual’ ∙ Mobilised against an Ebola organisations such as the World was exposed on the world stage, with epidemic spread over such a vast Health Organization, the US Center the loss of thousands of lives. What will geographic area, and in densely for Disease Control, International we have learned from these mistakes? populated urban centres. Medical Corps, GOAL, Save the Chil- dren, French Red Cross and others. ∙ Diverted human resources from Hundreds more were trained on-site other MSF emergency projects on in the affected countries. such a scale. International and national staff reassigned from ∙ Began clinical trials of experimen- headquarters and other MSF tal treatments and vaccines in the projects worldwide account for 213 midst of an outbreak. departures of the more than 1,300 international staff deployed to ∙ Addressed UN member states at respond to Ebola. the UN General Assembly, as we did in September 2014, declaring ∙ Opened an Ebola management that we collectively were losing the centre with 250 beds. Prior to this battle against Ebola. epidemic, a 40-bed centre was the largest we had built to respond to a large-scale epidemic.

|4 Sounding the alarm Unprecedented, out of control: a war of words

‘Mysterious disease’ even if never seen in this region before.’” virus’s spread so as to contain it. On 21 On 14 March 2014, Dr Esther Sterk in Three MSF emergency teams were March, laboratory confirmation of sam- MSF’s Geneva office was informed of deployed at once, one from Geneva, the ples sent to Europe came through late a ‘mysterious disease’ reported by the second from Brussels, both with rein- in the evening and on 22 March, the Ministry of Health in Guinea. Several forcements and supplies. The third, an Guinean Ministry of Health officially health staff taking care of the sick had MSF team based in Sierra Leone with declared the outbreak as Ebola. died and mortality was very high. Suspi- viral haemorrhagic fever experience, cious of Lassa viral haemorrhagic fever, was redirected over the border with Unprecedented spread she forwarded the report describing the some protection materials and was the The detective work of the epidemi- symptoms of the cases to Dr Michel Van first to arrive in Guéckédou, Guinea, on ologists revealed some unconnected Herp, MSF’s senior viral haemorrhagic 18 March. chains of transmission in different loca- fever epidemiologist in Brussels. tions in the Guinée forestière region, Acting on their suspicions, the team many of whom had family in neigh- “What jumped out at me from the med- immediately set up the priority activities bouring Liberia and Sierra Leone. ical report was the hiccups, a typical for an Ebola outbreak: caring for the sick symptom associated with Ebola,” recalls in Guéckédou hospital, training local “It was dawning on us that the spread of Dr Van Herp. “After further examination, health staff on how to protect them- the outbreak was something we’d never I said to my colleagues, ‘We’re definitely selves, raising awareness of the virus in seen before. Just days after we arrived, dealing with viral haemorrhagic fever, the community, conducting safe burials, an alert came in of suspected cases over and we should be prepared for Ebola, and running ambulances. Dr Van Herp the border in Foya, Liberia,” says Marie- joined them shortly after to begin out- Christine Ferir, MSF emergency coordi- MSF Ebola management centre, Kailahun, reach activities and to investigate sus- nator. “Then it went from bad to worse Sierra Leone. pected cases in the region, tracking the – a confirmed case showed up 650 km © Sylvain Cherkaoui/Cosmos Sylvain © away from Guéckédou in Guin- Dr Van Herp. “Ebola outbreaks ea’s capital, .” often come in waves. You can see a lull in one area, only to On 31 March, MSF publicly see the numbers spike again declared the outbreak as later. Until every last contact is ‘unprecedented’ due to the geo- followed up, victory cannot be graphic spread of the cases. declared.” What now seems obvious was, at the time, considered exag- Meanwhile, there was concern gerated and alarmist by many. all along about the puzzling On 1 April, the World Health absence of confirmed cases

Organization (WHO), via its chief © Amandine Colin/MSF over the border in Sierra Leone. spokesperson in Geneva, was Undiscovered outbreak in the first to call into question Guinea, March 31. MSF’s declaration, objecting Sierra Leone that the virus dynamics were In mid and late March, Ebola not unlike those of past outbreaks, nor resources to recognise and efficiently cases in Guinea were discovered that was the outbreak unprecedented. respond to Ebola, all contributed to the were reportedly coming from Sierra virus surging through the region. Leone. MSF immediately sent these “This was Zaire, the most deadly strain alerts to the Ministry of Health and of Ebola, spread out in an unprepared MSF teams spread thin the WHO in Freetown to be followed up region, while the sick and their care- Within the first two weeks, more than 60 locally. givers were moving on a scale we’d MSF international staff were deployed never seen before. Even the dead were to Guinea and had set up three Ebola From the onset of the epidemic, the US being transported from one village to management centres in Guéckédou, biotechnology company Metabiota and another,” recalls Dr Van Herp. Macenta and Conakry, whilst tracing Tulane University, partners of Sierra alerts and trying to carry out all the Leone’s Kenema hospital, had the lead “We balanced the risks of potentially other ‘normal’ priority activities in an in supporting Sierra Leone’s Ministry of fuelling further panic against the knowl- Ebola outbreak. Health in investigating suspected cases. edge that this epidemic would be far Their investigations came back Ebola- more complicated to control than any “The problem initially was not so much negative, while their ongoing surveil- other before,” says Dr Van Herp. “I had the number of cases, but that the hot- lance activities seem to have missed no doubt it was unprecedented – our spots were spread out in so many loca- the cases of Ebola that had emerged in alarm bells were ringing from the start.” tions,” says Dr Armand Sprecher, MSF the country. public health specialist. “In the past, Virus without borders Ebola stood still for us and we could “We had prioritised our resources on Ebola had been stealthily spreading quickly set up operations in the same areas with confirmed cases in Guinea undetected for more than three months. area to contain it. This time, people and Liberia,” says Ferir. “There was It is not unusual for Ebola to go undiag- moved around much more and Ebola little room to question the formal infor- nosed for a substantial period of time; travelled with them. So we had to rep- mation coming from Freetown that the the past eight Ebola outbreaks each licate activities and move around our investigations showed no confirmed took two months on average to be dis- handful of experienced staff like chess cases in Sierra Leone.” covered and investigated. Ebola’s symp- pieces, trying to gauge where they’d be toms are easily confused with other dis- best placed to act fast.” Then, on 26 May, the first confirmed eases, such as cholera and malaria, and case was declared in Sierra Leone and experts trained to recognise it are rare, On 31 March, cases were confirmed in the Ministry of Health called on MSF to both in MSF and in the world at large. Liberia. One of the MSF teams in Guinea intervene. MSF’s priority became set- was redirected to set up isolation wards ting up an Ebola management centre in However, past outbreaks took place in Monrovia and Foya, and train health- Kailahun, the epicentre at that time in mostly in remote villages in central care workers on how to tackle the virus. Sierra Leone. With MSF’s teams already and eastern Africa, where they were Only 12 cases were reported in ten days, spread thin, and due to the high number more easily contained. In a twist of geo- and by mid-May the situation there of cases, MSF lacked the capacity to graphic fate, Ebola erupted at the junc- seemed under control. After 21 days simultaneously manage essential out- tion of Guinea, Liberia and Sierra Leone, without new cases and having trained reach activities such as awareness where people regularly move across the health staff in Liberia, the MSF team raising and surveillance. porous borders. departed to reinforce those in Guinea. “When we set up operations in Kailahun, Fear and suspicion of the unknown virus, “Although we also began to see a we realised we were already too late. unsafe burial practices, mistrust in poli- decrease of cases in Guinée forestière There were cases everywhere, and we ticians, the hiding of cases, and a weak region in May, we stayed vigilant in case built the centre with 60 beds, rather public health system, which lacked the of hidden chains of transmission,” says than the 20 we started with in Guinea,” |6 says Anja Wolz, MSF emergency coor- dinator. “The Ministry of Health and the partners of Kenema hospital refused to THE SIX KEY ACTIVITIES TO BRING AN EBOLA share data or lists of contacts with us, OUTBREAK UNDER CONTROL so we were working in the dark while cases just kept coming in.” 1. Isolation and care for patients: Isolate patients in Ebola management After a short period of raised hopes in centres staffed by trained personnel and provide supportive medical care May as cases appeared to be declining in and psychosocial support for patients and their families. Guinea and Liberia, the hidden outbreak 2. Safe burials: Provide and encourage safe burial activities in the in Sierra Leone mushroomed and reig- communities nited the outbreak for its neighbours. 3. Awareness-raising: Conduct extensive awareness-raising activities to help communities understand the nature of the disease, how to protect them- Today, describing the epidemic as selves, and how to help stem its spread. This works best when efforts are ‘unprecedented’ is stating the obvious, made to understand the culture and traditions of local communities. though for months MSF felt alone in 4. Disease surveillance: Conduct and promote thorough disease surveillance this analysis. But MSF was not pre- in order to locate new cases, track likely pathways of transmission, and pared for just how unprecedented the identify sites that require thorough disinfection. outbreak would become, both in terms 5. Contact-tracing: Conduct and promote thorough tracing of those who have of its scale and in terms of the leading been in contact with Ebola-infected people. If contacts are not mapped role the organisation would be forced to and followed up, it undermines all the other activities and the disease will assume. continue to spread. 6. Non-Ebola healthcare: Ensure that medical care remains available for Out of control people with illnesses and conditions other than Ebola (malaria, chronic In late June, MSF teams counted that the diseases, obstetric care, etc). This includes implementing stringent policies virus was actively transmitting in more to protect health facilities and health workers, particularly in areas where than 60 locations in Guinea, Liberia they might come into contact with patients. and Sierra Leone. Facing an exception- ally aggressive epidemic and unable to do everything, MSF teams focused on damage control and prioritised the majority of resources on running Ebola management centres. Critically it was not possible to roll out the full range of containment activities in all locations.

Across the three countries, local health- care workers were tragically dying by the dozens. In Ebola outbreaks, health facilities without proper infection con- trol often act as multiplying chambers for the virus, and become dangerous places for both health workers and patients. This outbreak was no different, but it happened on a massive scale.

“We raised the alarm publicly again on 21 June, declaring that the epidemic Joffrey Monnier/MSF © was out of control and that we could Gbando, Guinea. MSF epidemiologist Dr Michel Van Herp explains what is Ebola, how to not respond to the large number of new protect yourself and avoid transmission. cases and locations alone,” recalls Dr Bart Janssens, MSF director of oper- ations. “We called for qualified med- for declaring that the epidemic was out “In the end, we did not know what words ical staff to be deployed, for trainings of control. At the same time, govern- to use that would make the world wake to be organised, and for contact tracing ment authorities and members of the up and realise how out of control the and awareness-raising activities to WHO in Guinea and Sierra Leone down- outbreak had truly become,” recalls Dr be stepped up. But effectively none of played the epidemic’s spread, insisting Janssens. these things followed our appeal for it was under control and accusing MSF help. It was like shouting into a desert.” of causing unnecessary panic. Although the writing was on the wall, again MSF was accused of alarmism 7| Global coalition of inaction Lack of political will, expertise or simply fear?

Reluctance and obstructions the country by excluding probable and its normative work and technical advice The governments of Guinea and Sierra suspected cases. Needless obstacles to countries worldwide. Its ability to Leone were initially very reluctant to made responding more difficult for MSF respond to emergencies and outbreaks recognise the severity of the outbreak, teams, who were refused access to con- is less robust, lacking the human which obstructed the early response. tact lists and had to start from scratch resources and emergency prepared- This is far from unusual in outbreaks in determining which villages were ness to hit the ground running and care of Ebola – or indeed other dangerous affected and where and how to respond. for patients. infectious diseases; there is often little appetite to immediately sound the Faced with an explosion of Ebola cases “When it became clear early on that it alarm for fear of causing public panic, in the summer, the Liberian authorities was not simply the number of cases disrupting the functioning of the country were transparent about the spread of that was creating concern, but indeed and driving away visitors and investors. cases, though few outside the country the epidemic’s spread, clear direction stepped forward to respond to their was needed and leadership should have On 10 May, Guinean media reported the urgent requests for help. The govern- been taken,” says Christopher Stokes, president of Guinea complaining that ment was wrongly accused of scare- MSF general director. “The WHO should MSF was spreading panic in order to mongering by its own population, who have been fighting the virus, not MSF.” raise funds. In Sierra Leone, the gov- thought it might be a ploy to raise inter- ernment instructed the WHO to report national assistance. There was little sharing of informa- only laboratory-confirmed deaths in tion between countries, with officials June, reducing the death toll count in A vacuum of leadership relying on the WHO to act as liaison The WHO plays a leading role in pro- between them. It was not until July MSF Ebola management centre, Freetown, tecting international public health, and that new leadership was brought into Sierra Leone. it is well known that its expertise lies in the WHO country offices and a regional © Yann Libessart/MSF Yann ©

|8 insisted on the urgent need to deploy an effective response in the region and made a dramatic call for extra support to be sent to Liberia.

“I finished my presentation at the GOARN meeting by saying that I was receiving nearly daily phone calls from the Ministry of asking for support, and that MSF had no more experienced staff I could send to them,” recalls Marie-Christine Ferir. “I remember emphasising that we had the chance to halt the epidemic in Liberia if help was sent now. It was early in the outbreak and there was still time. The call for help was heard but no action

© Julien Rey/MSF Julien © was taken.”

MSF Ebola management centre, Guéckédou, for Disease Control (CDC) with its lab- While coordination was officially organ- Guinea. oratory and epidemiological exper- ised following the GOARN meeting and tise. However, both WHO in the African the regional meeting in Accra in early operations centre was established in Region (WHO AFRO) and its Geneva July, there was a clear lack of leader- Conakry to oversee technical and oper- headquarters did not identify early on ship from the WHO: decisions on setting ational support to the affected countries. the need for more staff to do the hands- priorities, attributing roles and respon- on work, nor did it mobilise additional sibilities, ensuring accountability for the Instead of limiting its role to providing human resources and invest early quality of activities, and mobilising the advisory support to the national author- enough in training more personnel. resources necessary were not taken on ities for months, the WHO should have the necessary scale. recognised much earlier that this out- “We mobilised all our haemorrhagic break required more hands-on deploy- fever experts and experienced med- “Meetings happened. Action didn’t,” ment. All the elements that led to the ical and logistical staff, many of whom says Ferir. outbreak’s resurgence in June were returned multiple times to the region. also present in March, but the analysis, But we couldn’t be everywhere at once, Catastrophe in Liberia recognition and willingness to assume nor should it be our role to single-hand- In late June, MSF emergency coordi- responsibility to respond robustly were edly respond,” says Brice de le Vingne, nator Lindis Hurum arrived in Mon- not. MSF director of operations. “MSF does rovia, Liberia. With few experienced not have an Ebola army with a ware- staff left to deploy, her small team of Lack of expertise, short of staff house of personnel on standby. We rely three was sent to support the Ministry Given that Ebola outbreaks in the past on the availability and commitment of of Health with technical advice in con- occurred on a much smaller scale, the our volunteers.” tact tracing and water and sanitation. number of people with experience of the They assisted in setting up a 40-bed disease was limited; there were simply Meanwhile, exhausted national health centre to be run by the US relief group not enough experts worldwide to stem workers bravely and tirelessly stepped Samaritan’s Purse, and began providing the tide of this epidemic. up and continued to tackle the out- coordination support to the Ministry of break each day, while facing stigma and Health. As the virus began spreading For MSF, the most significant limita- fear in their own communities. Some like wildfire in the capital city, the centre tion was the lack of experienced staff to MSF locally-hired staff were aban- quickly became overwhelmed with sick deal with an outbreak on this scale. The doned by their partners, ejected from patients. Ebola ‘veterans’ in MSF numbered only their homes, their children ostracised around 40 at the onset of the outbreak. by playmates. Their dedication and Then, at the end of July, two Samari- They had to simultaneously set up and extraordinary hard work over the past tan’s Purse staff, US nationals, became run operations on the frontline, as well year is parallel to none. infected with Ebola, and the organi- as coach inexperienced staff. Now more sation suspended operations in the than 1,300 international staff and more Liberia: SOS call in June only two Ebola management centres than 4,000 national staff have been At the end of June, there was a meeting in Liberia – in Monrovia and in Foya, in deployed over the past year. in Geneva of the WHO’s Global Alert and the northwest of the country. No one The WHO is internationally mandated to Outbreak Response Network (GOARN), stepped forward to take their place to lead on global health emergencies and a key platform that pools technical and support the Ministry of Health in caring possesses the know-how to bring Ebola human resources in response to dis- for patients. under control, as does the US Centers ease outbreaks. At the meeting, MSF 9| I think it’s fair to say that we are Doctors Without Borders, but we are not without limits. And we’ve reached our limit. It’s very frustrating, because I see the huge needs but I simply don’t have the human resources. We have the money thanks to our donors. We have the will. We certainly have the motivation, but I don’t have enough people to deal with this.”

Lindis Hurum © Caitlin Ryan/MSF MSF Emergency Coordinator in Monrovia August 2014 Monrovia, Liberia. Construction teams building what would become ELWA 3, the world’s largest Ebola management centre with 250 beds.

Painful discussions ensued in MSF. We “Even though ELWA 3 was the big- felt that we were already operating at gest treatment centre in history, we 100 percent, with our teams already knew it was not enough,” recalls Rosa overstretched in Guinea and Sierra Crestani, MSF Ebola task force coor- Leone, and there was a concern that dinator. “We were desperate because taking over the centres in Liberia would we knew that we couldn’t do more, and push MSF over the limit. What if mis- we knew exactly what those limitations takes were made, staff became infected meant. It meant there would be dead and the project collapsed? This had bodies in homes and lying in the street. been the case in July in the Ministry It meant sick people unable to get a bed, of Health hospital in Kenema, Sierra spreading the virus to their loved ones.” Leone, as well as for Samaritan’s Purse in Liberia. What if pushing the limits ELWA 3 forced to close its gate broke MSF’s ability to respond, with no 23.5 hours a day visible replacement? By the end of August, ELWA 3 could only be opened for 30 minutes each morning. “In a way the decision was made for us Only a few patients could be admitted to – we couldn’t let Monrovia sink further fill beds made empty by those who had into hell,” recalls Brice de le Vingne. died overnight. People were dying on “We would have to push beyond our the gravel outside the gates. One father threshold of risk, and we would have to brought his daughter in the boot of his send coordinators without experience car, begging MSF to take her in so as to in Ebola, with only two days of inten- not infect his other children at home. He sive training. It would be dangerous, but was turned away. we’d have to find a way to intervene in Monrovia and Foya.” “We had to make the horrendous deci- sion of who we could let into the centre,” Trainings began in earnest in Brus- says Rosa Crestani. “We had two choices sels headquarters and in the field, – let those in who were earlier in the dis- embarking on the most extensive ease, or take in those were who dying knowledge-transfer exercise in MSF’s and the most infectious. We went for a history, with more than 1,000 people balance. We would take in the most we trained. At the same time, an MSF team safely could and the sickest. But we kept deployed to Foya, while construction our limits too –we refused to put more began of MSF’s ELWA 3 centre in Mon- than one person in each bed. We could rovia, eventually reaching 250 beds. only offer very basic palliative care and there were so many patients and so few staff that the staff had on average only |10 one minute per patient. It was an inde- west Africa, finally the world began to I’m horrified by the scribable horror.” wake up.” scale of the centre The turning point – Ebola crosses Fear factor & global paralysis we’re constructing the ocean International recognition of the severity and the horrible On 8 August, the WHO at last declared of the outbreak finally hit home in conditions inside, what people the outbreak a “public health emer- August, but an increased response was are enduring. It’s horrible gency of international concern,” a pro- still slow to get off the ground. Was it what our staff are having to cedure that flipped the switch to unlock fear of the virus that delayed the quick do, with the risk and the heat. funding and activate expert capability response that was so desperately faster. By this time, more than 1,000 needed? We’re struggling to deal with people had already died. What finally the number of patients. We’re triggered the change to emergency It is true that Ebola provokes an under- trying to adapt and build response mode? standable and almost universal fear as the need increases, but that is unequalled by any other disease. we’re not keeping up. We feel At the end of July, a US doctor working The lack of effective treatment, the for Samaritan’s Purse tested positive painful and distressing symptoms and tremendous guilt and shame for Ebola and was evacuated back to the high mortality rate cause extreme that we can’t adequately the US for medical care. Thereafter, the public anxiety, not only in the commu- address the needs of the first case of Ebola was diagnosed out- nities affected, but also among health- people.” side west Africa; the patient, who had care workers themselves, who are often recently returned from west Africa, was among the first to fall ill, further dis- Brett Adamson treated at a hospital in Dallas, US. Then couraging additional volunteers from MSF field coordinator in Monrovia a Spanish nurse who treated a Spanish coming forward to help. August 2014 citizen infected with Ebola tested posi- tive for the virus, becoming the first Natural disasters like floods and instance of human-to-human transmis- earthquakes usually prompt a gen- sion of Ebola outside Africa. erous outpouring of resources and direct intervention from aid organisa- “The lack of international political will tions and concerned states, but fear of was no longer an option when the real- the unknown and lack of expertise in isation dawned that Ebola could cross Ebola paralysed most aid agencies and the ocean,” says Dr Joanne Liu, MSF donors. The margin of error required to international president. “When Ebola safely run an Ebola management centre became an international security threat, is so slim that meticulous training is and no longer a humanitarian crisis necessary to prepare for the challenge. affecting a handful of poor countries in © Caitlin Ryan/MSF

Monrovia, Liberia. An MSF medical team speaking with the sick queuing outside the gates of ELWA 3 management centre. The team is assessing who can be admitted to the triage for possible admission to the centre.

11| “We tried to stress that not all of the of the organisation to respond to the “We were in uncharted waters and could response involves ‘space suits.’ Con- outbreak. not wait the two months necessary tact tracing, health promotion and dis- for other aid agencies to train up and tribution of soap, chlorine and buckets By late August, the virus had exploded respond,” says Dr Liu. “Who else could were all urgently needed,” says Dr across the three countries. After dis- step into the breach immediately before Jean-Clément Cabrol, MSF director of cussions with other aid agencies, it was the epidemic spiralled further out of operations. “Not all activities are con- calculated that it would take a minimum control?” fined to the high-risk zone, but every- of two to three months for them to train thing needed to be done by someone – and be ready to deploy. Meanwhile the and on a massive scale.” However, most clock was ticking and Ebola was win- aid organisations were very reluctant to ning. Funding was no longer the main take on the perceived risk of working problem and untrained voluntary help with Ebola, fearing that they would not would clearly not be enough. Skilled be able to protect their staff. and well-equipped medical teams were needed on the ground immediately. MSF was also not immune. Over the years, MSF’s experience with Ebola had been largely centralised within a group of experts and it was considered a spe- cialism. Among the parts of MSF with little or no experience of Ebola, there was some initial reluctance to intervene immediately. MSF should have been faster at mobilising the full capacity

EBOLA CROSSES TO NIGERIA, SENEGAL AND MALI

Quick responses avert disaster Mali Concerns of an even wider regional outbreak were well founded. 8 cases, 6 deaths When Ebola entered Nigeria, Senegal and Mali, MSF supported The first case in Mali, a two-year-old their governments in containing the disease. With the epidemic girl, appeared on 23 October. MSF already raging in neighbouring countries, all three governments sent a team to help construct an Ebola management centre in Bamako were alert to its potential spread, which helped ensure an and in the town of Kayes where the effective response. child had died, as well training local staff in case management, surveil- “As our teams were overstretched in and implementing rigorous infec- lance and social mobilisation. MSF the three most affected countries, tion control measures, was critical in went on to take a more hands-on we focused on providing technical avoiding a widespread epidemic. approach than in the other two coun- support, with the level of direct MSF tries, including managing the two management varying according to the Senegal centres in Bamako and Kayes and local capacity that already existed,” 1 confirmed case, 0 deaths carrying out safe burials and sur- says Teresa Sancristoval, MSF emer- MSF conducted an Ebola training in veillance. This was due to Mali’s less gency coordinator. A similar strategy April 2014 at the request of the Sen- robust health system and a lack of had been planned for Monrovia before egalese government. The trained sufficient resources to manage the the epidemic spiralled out of control. teams then took care of the Ebola outbreak, as well as less support case that arrived in Dakar in August. from other partners. Nigeria An MSF team of x advisors sup- 19 confirmed cases, 1 suspected case, ported the Ministry of Health to set Nigeria, Senegal and Mali all had the 8 deaths up an Ebola centre and train the staff benefit of world-class laboratories In late July, Ebola first arrived in in case management, contact trac- which could produce fast test results. Nigeria via an air passenger from ing and social mobilisation. Within a The experience in all three countries Liberia. Despite the virus enter- week, 100 percent of the contacts had highlights the importance of strong ing Lagos, a city of 20 million people, been traced. Nine regions considered surveillance and rapid response at and Port Harcourt, with one million most at risk were also trained in out- the beginning of an outbreak. inhabitants, overall just 20 people break response. were affected. The government’s fast response, including deploying signifi- cant human and financial resources |12 Last hope to control the outbreak MSF calls on the UN Member States to deploy civilian and military biohazard assets

On 2 September, Dr Joanne Liu, MSF’s We cannot cut off the affected coun- be military units with some level of bio- international president, made a fervent tries and hope this epidemic will sim- logical warfare expertise,” says Christo- appeal to the UN member states in New ply burn out. To put out this fire, we pher Stokes. “Faced with continuing to York. In her speech, she pleaded: must run into the burning building.” turn away patients at the hospital gate while waiting for other volunteers to “Many of the member states here today This was a very unusual call for MSF, train up and deploy, or calling for help have invested heavily in chemical known for keeping a safe distance from from military agencies, the choice was and biological response. To curb the military and security agendas to pro- clear.” epidemic, it is imperative that states tect its independence in conflict zones. immediately deploy civilian and mili- However, the catastrophe unfolding on After having sought agreement with the tary assets with expertise in biohaz- the ground could clearly not be brought heads of state of Liberia, Sierra Leone, ard containment. I call upon you to under control by international aid and Guinea, MSF called for field hospi- dispatch your disaster response teams, organisations alone – a desperate call tals with isolation wards to be scaled up, backed by the full weight of your logis- of last resort had to be made. trained personnel to be sent out, mobile tical capabilities. laboratories to be deployed to improve “We considered that the only organisa- diagnostics, and air bridges established MSF Ebola management centre, Monrovia, tions in the world that might have the to move people and material to and Liberia. means to fill the gap immediately might within west Africa. © Caroline Van Nespen/MSF Van Caroline ©

13| on the ground did not. Much to MSF’s disappointment, the majority of the BRIEFING THE UN SECURITY COUNCIL military effort deployed in October and November was limited to support, coor- Following the speech of MSF international president Dr Joanne Liu at the dination and logistics for the efforts UN General Assembly in New York, Liberian MSF team leader Jackson K.P. of international aid organisations and Naimah followed suit, speaking via videoconference at the UN Security Council local authorities. on 18 September: Although very much needed, the med- “Right now, as I speak, people are sitting at the gates of our centres, literally ical facilities built to treat local and for- begging for their lives. They rightly feel alone, neglected, denied – left to die a eign healthcare workers were provided horrible, undignified death. We are failing the sick because there is not enough to help ensure that others could treat help on the ground.” patients, rather than offering direct care themselves to the wider community. The UN Security Council ruled that the Ebola outbreak constituted a threat to international peace and security and unanimously passed a resolution urging “We insisted that simply constructing UN member states to provide more resources to fight the outbreak. the physical structures would not be enough, and that transferring the Thereafter, taking stock of the inability of the WHO to provide the necessary risk to inexperienced aid workers and leadership and coordination to combat the Ebola outbreak between April and exhausted local health workers was September, UN Secretary-General Ban Ki-Moon established the creation of the unacceptable,” says Dr Liu. “There was first ever UN health mission, the UN Mission for Ebola Emergency Response a clear reluctance to jump in and care (UNMEER). for patients. They wanted to help, but not to do anything risky – US helicopters would not even transport laboratory samples or healthy personnel returning from treating patients.”

Although the appeal for the deployment of biohazard teams was not met, the assistance that did arrive was welcome. This engagement marked the symbolic beginning of a substantial interna- tional response, and served to reassure people that help was finally underway.

Providing intensive treatment facili- ties for healthcare workers also reas- sured international aid agencies, who then felt able to offer stronger assur- ance before deploying their staff, as © Fernando Calero/MSF Fernando © well as bolstering local health workers and authorities. Meanwhile some posi- Monrovia, Liberia. MSF team leader Jackson stabilisation,” says Stokes. “What if mil- tive signs were coming from Lofa county K. P. Naimah, who addressed the UN itaries deployed and proved more dam- in northwest Liberia. By late October, no Security Council in September, discussing aging than helpful? Then we would be new patients were being reported at with Dr Joanne Liu, MSF’s international president. held responsible for having called them MSF’s centre in Foya. Other organisa- in the first place.” tions came on board to take over the MSF also ran the risk of confirming sus- remaining activities and surveillance, A risky call picions, levelled at all aid organisations, allowing MSF teams to withdraw from MSF insisted that any military assets of being part of a security or political Lofa county and redirect their efforts to and personnel deployed should not agenda. This suspicion in armed conflict areas with unmet needs. be used for quarantine, containment could put both aid workers and patients or crowd control measures, because in the firing line of opposing forces. “The comprehensive efforts and strong forced quarantines have been shown to collaboration with the community cer- breed fear and unrest, rather than stem Help belatedly arrives but not tainly played a crucial role in reducing the spread of Ebola. exactly what was asked for the number of cases in Lofa county,” “Whilst social unrest and fears of state Helpful pledges of equipment and logis- says Dorian Job, MSF deputy emer- collapse ran rampant, we feared that our tical support came in September, yet gency manager. “This was one of the call would be misconstrued or inten- sufficient deployment of qualified and first moments we felt that the epidemic tionally twisted into a call for armed trained medical staff to treat patients could be controlled.” |14 © Julien Rey/MSF Julien ©

MSF Ebola management centre, Conakry, “From the very outset, this epidemic Guinea. Each night all the waste from the has been defined by its unpredictability, high-risk zone that cannot be chlorinated reach and speed,” says Karline Kleijer, must be burnt on site. MSF emergency coordinator. “If the epi- demic had not started to recede, the Cases decline Ebola management centres built in the Late in 2014, by the time that the mili- region would have been indispensable.” taries were building new Ebola manage- ment centres, cases began to decline in In December, the international response other regions too. The reason behind was striving to deliver what had been the drop in cases is difficult to attribute promised three months before. By the to any single factor. Public behaviour time they deployed, it was difficult to changes, greater availability of beds, adapt and adjust to the rapidly changing increased efforts to control infection epidemiology of the outbreak, resulting and more safe burials have all contrib- in resources allocated to some activities uted to the decrease. that were no longer the priority.

15| Doctors without a cure… but with care The medical challenges of Ebola

A virus that kills more than half your percent. There are still many unknowns, old), and viral load (high levels of virus patients, with no available treat- both medically and epidemiologically, in the blood on admission), are factors ment to fight it, is a doctor’s worst about Ebola and how to best combat it that appear to determine the highest nightmare. clinically.” mortality rates.

Still, more than 2,300 patients have Several elements may impact mortality: Laboratory constraints emerged Ebola-free in MSF’s centres in the severity of infection at admission One of the key constraints for MSF med- Liberia, Guinea and Sierra Leone. Each (viral load), the age of the patient, gen- ical teams in delivering more individual- one is celebrated as a victory. eral previous health status, coexisting ised patient care was the limitations in infections, nutritional status, intensive monitoring their biochemistry. “We try to provide the best supportive supportive care, or a combination of all care we can, as well as alleviate our of these. “Some patients are seemingly on the patients’ symptoms and suffering,” says mend, walking, talking and eating, then Dr Armand Sprecher. “Our experience MSF is documenting and researching sadly and inexplicably pass away an from past outbreaks demonstrates that our data to examine these factors, hour later. It is not yet known which fac- good clinical care can reduce overall which will be shared with the research tors allow some people to recover while case fatality rates by between 10 and 15 community. So far, the main results others succumb,” says Dr Sprecher. “To suggest that the age of the patient try to understand how aggressively the MSF Ebola management centre, (before 5 years old and after 40 years virus is attacking the body, monitoring Guéckédou, Guinea. © Sylvain Cherkaoui/Cosmos Sylvain ©

|16 We are all scared of Ebola, and rightfully so. It’s something about the way it is emitted – through the blood, sweat and tears of human beings. Imagine being the patient: you’re sick and scared, your doctor is fearful, and when he comes to you he’s unrecognisable in a space suit. And what are my tools to heal my patient? A bed, three meals, fluids, tablets, antimalarials, painkillers.

© Sylvain Cherkaoui/Cosmos Sylvain © I do my best to make sure your immune system is able to fight Ebola as best it can. But in the MSF Ebola management centre, us to spending an hour maximum inside end I’m physically isolated from Guéckédou, Guinea. MSF nurse in the at a time,” says Dr Hilde De Clerck. undressing area after exiting the high-risk my patients and, when I get to zone. “Inside the high-risk zone, I have to plan the most crucial activities I can squeeze them, I can only say you have into that hour. It’s frustrating and upset- around 50 percent chance of patients’ electrolytes and analysing ting that that I can’t spend unlimited dying and I can do very little their blood chemistry helps define the time with my patients or connect with about it for you.” best care you can provide.” them as I usually would, with a smile or a comforting human touch.” Dr Javid Abdelmoneim Doing this requires advanced laboratory On a knife-edge MSF doctor in Sierra Leone support capacity, which was not always September-October 2014 available, either within MSF or through In an Ebola outbreak, MSF teams work external partners, particularly in the on a knife-edge addressing both patient first months of the outbreak. The lab- care and staff safety. oratory capacity provided by key part- ners who came on board early in the MSF had called for help as the epidemic epidemic was overwhelmed with the sped out of control because, at the most high numbers of cases that needed to severe periods of the outbreak, teams be diagnosed, while some were unpre- were unable to admit more patients or pared to run biochemistry tests. provide the best possible care. This was extremely painful for an organisation As early as April, MSF teams in Guinea of volunteer medics, leading to heated were using ISTAT machines for elec- exchanges and tensions within MSF. trolyte monitoring. However, practical challenges as well as competing priori- “Our duty of care for our staff is certainly ties meant that it was not until October crucial, as in any MSF project world- that they were reinstated in MSF’s wide,” says Henry Gray, MSF emergency centres. coordinator. “Though we have invested heavily in personal protective equip- Working in the hot zone ment, training and security protocols, In the eight-piece ‘space suits’ worn by we have painfully learned there is never MSF medical teams on the ground tem- zero risk.” peratures can reach 46 degrees Celsius. One of the most dangerous moments is “We were also under pressure to set removing the soiled suit, a meticulous an example and show that it was pos- 12-step process that is frustratingly sible to treat Ebola safely, in an effort complex, can take up to 20 minutes, and to mobilise others to intervene,” says is repeated at least three times per day. Brice de le Vingne. “If we took even more risks and too many staff fell ill, “We have to move and breathe slowly we’d be unable to maintain trust with due to the overpowering heat, limiting our teams or recruit new volunteers, 17| resulting in the possible collapse of our in the midst of the outbreak. The first centres with no one to take our place.” Ebola experimental treatment trial in As the number of cases grew, MSF staff west Africa, for the drug favipiravir, were challenged by having increasingly began at MSF’s centre in Guéckédou, limited time with each patient. At cer- Guinea on 17 December 2014. tain times, admissions were so high that © Peter Casaer/MSF Peter © there were not enough staff to safely “Starting clinical trials in a matter of manage intravenous hydration, as was months in the midst of a complex the case in Monrovia in September. It humanitarian crisis has never hap- was not just a matter of insert a drip pened before, much less in risky bio- safely, but also of having enough team hazard conditions,” says Dr Micaela members to carry out the necessary Serafini, MSF medical director. monitoring, follow-up of fluid hydration for patients and good infection control. The trial protocols were designed to ensure that disruption to patient care When a member of staff became would be minimal, that internationally- infected, fear had an impact, and some- accepted medical and research eth- times led to more restrictive care imme- ical standards were respected, and that diately afterwards. MSF teams strived sound scientific data would be produced to quickly overcome these barriers and and shared for the public good. to return to optimal levels of individual- Guéckédou, Guinea. MSF nurse handling ised care with the minimum of delay. favipiravir tablets, at the MSF Ebola ma- Will these ongoing efforts be the final nagement centre where clinical trials of the game-changer in the current epidemic? Imperfect offerings treatment began on 17 December 2014. In September, when there were not “Possibly not, as the notably lower enough beds in the centres in Monrovia, number of cases may outpace the con- MSF began distributing family protec- Most of the research had been con- clusive results of the studies. The virus tion and home disinfection kits for more ducted by public institutes and small may just escape the snare of an effec- than 600,000 people in the city. The kits firms, supported by public defence tive vaccine and treatment this time were designed to give people some pro- funding, and justified by the bioter- around,” says Dr Bertrand Draguez, tection should a family member become rorist risk posed by the highly infectious MSF medical director. “But the ongoing ill, as well as allowing people to disin- viral disease. The majority of research studies are certainly not for nothing. fect their homes to reduce infection and development was dedicated to vac- Now, with the data collected from the risk. One of the key targets was health cines and post-exposure prophylaxis, trials, the momentum must be sus- workers, who were often asked to help with a focus on stockpiling products for tained to ensure that drugs, vaccines care for people in their communities Western markets. and diagnostics are ready and acces- when treatment centres were full. sible for the next epidemic.” But as the epidemic spiralled fur- “Though we knew these kits were not the ther out of control and repeated calls To that end, it is essential that there is solution to the Ebola crisis in Monrovia, for help were slow to materialise, MSF a real commitment from regulatory we were forced to take unprecedented became increasingly aware that accel- bodies, pharmaceutical companies and and imperfect measures,” recalls Anna erated product development was ever governments for fair access to vac- Halford, MSF coordinator for the distri- more urgently needed for the response. cines and treatments in Ebola-affected bution. “They were a stopgap solution countries. The expertise, research and to allow people to try and protect them- “Research and development finally results must be shared collectively. selves from a sick family member for a accelerated in early August, when the short time until they could be admitted WHO confirmed that using Ebola prod- Had an effective treatment or vaccine to a management centre.” ucts not yet tested on humans was eth- existed, thousands of deaths could have ical and even encouraged, given the been avoided. Doctors without a cure exceptional nature of the outbreak,” When the outbreak began, there was no says Julien Potet, policy advisor for MSF vaccine, drug or rapid diagnostic test on Access Campaign. “Public and private the market proven to be safe and effec- research sectors fast-forwarded the tive against Ebola in humans. process to start clinical trials from what usually takes years to mere months.” Ebola had never been considered a pri- ority for big pharmaceutical companies, In August, MSF made the first-time as it was perceived as affecting only a decision to partner with research insti- limited number of economically dis- tutions, the WHO, Ministries of Health advantaged patients in short-lived and and pharmaceutical companies to trial remote outbreaks in Africa. experimental treatments and vaccines |18 MSF INTERNAL CHALLENGES This Ebola outbreak presented MSF with substantial internal challenges, many of which require further deliberation. Whilst others have lauded us for our response to the outbreak, we are very conscious too of where we fell short. This includes, but is not limited to:

∙ A year of competing crises. 2014 ∙ Mobilising the full force of capacity ∙ Adapting our response. Given that was a very demanding year for MSF, within the wider MSF network. Over our resources were overstretched, as for other frontline humanitarian the years, MSF’s experience with could we have adapted our strategy organisations. Simultaneous crises viral haemorrhagic fevers had been in deciding what to focus on in each in , South largely centralised within a group location, or did we go into reactive, , Ukraine and Syria, all of of experts and it was considered damage control mode? For example, which demanded the attention of our a specialism. Among the parts of how could we have done more to most experienced staff, made it hard MSF with less Ebola experience, address the deep public mistrust in to ensure that Ebola was given the there was a reluctance to intervene Guinea? And could we have pushed attention and human resources it immediately. MSF should have been more forcefully in Sierra Leone at the required, particularly in the first five faster at mobilising the full capacity beginning? months of the outbreak. of the organisation to respond to the outbreak. ∙ Diverted priorities. At times it felt ∙ The duty of care to employees. Even as if we were trying to do everything within MSF, an organisation with a ∙ Patients or public health? There everywhere. Difficulties in organising higher tolerance of risk than many was an impossible tension between efficient medical evacuation arrange- other aid agencies, Ebola was consid- curbing the spread of the disease, ments, fighting travel bans imposed ered especially hazardous. The lack and providing the best clinical care to without scientific evidence, helping of treatments available to infected each patient. This became particu- to convince airlines such as Brussels staff and the high mortality rate cre- larly acute in August and September Airlines to continue flights to the ated an unparalleled fear among staff. in Liberia when case numbers region, training other organisations, Medical evacuations for international spiked and our facilities became and managing fear and often hysteri- staff could not be guaranteed by their overwhelmed. At times we were only cal public opinion in ‘home’ societies respective governments, and staff providing the most basic palliative all diverted attention away from the volunteering to go to west Africa had care to patients and prioritising the critical needs in the field. to accept that they might fall sick admission of people who were highly and be unable to return home. In infectious in order to reduce the addition, the fear of staff infections spread of Ebola in the community. We meant that MSF insisted on the deliberately increased the number most stringent safety protocols – for of beds, acknowledging that this example limiting the time permitted would necessitate a drop in the level in the high-risk zone – thus reduc- of care – for many an unbearable ing the freedom of medical staff to compromise. determine and provide the quality of care for patients that they would have ∙ Staff turnover. Ebola outbreaks wanted. This caused much anguish consume a huge amount of resourc- amongst MSF medical staff. es, particularly staff. The duration of frontline field assignments for international staff during the Ebola outbreak was much shorter than usual – a maximum of a few weeks rather than months. This was to ensure that they remained alert and did not become too exhausted or complacent. However an unintended consequence of this turnover was that details were not always handed over; lessons had to be learned, then learned again.

19| Looking to the future

Despite more than 40 years of working in some of the world’s worst humanitar- ian crises, this Ebola outbreak has wrought an exceptionally heavy toll on MSF’s Still not over staff, and particularly on our west African colleagues. Not since the early days In early 2015, cases were still on the of HIV care have MSF staff sustained the loss of so many patients dying in our decline, causing some speculation facilities, without the tools to save them – and never in such an intense short about the end of the epidemic. Liberia period of time, with death fast-forwarding from 10 years to 10 days. is currently on the countdown to zero cases, with no new cases presenting Although many unknowns remain about sentence for pregnant women, while since early March. However the overall the virus, MSF has learned much over now specialised care has seen women number of cases in the region is still the past year, from improving the design emerging Ebola-free from MSF’s fluctuating and has not significantly of Ebola management centres to devel- centres. declined since late January. oping protocols for the care of pregnant women and children. Before this out- Over the past year, MSF teams have had With more organisations on the ground break, Ebola was thought to be a death to make difficult choices in the face of and enough beds for Ebola patients, competing priorities and in the absence MSF teams continue running centres Sierra Leone. Piloting began in January of available treatment and enough and are able to focus on filling gaps in for a new electronic, tablet-based patient resources. As in all MSF programmes, outreach activities such as surveillance, data management system in MSF’s Ebola there have been operational and med- contact-tracing and social mobilisation. treatment centres in Sierra Leone. The specially developed hardware is easy for ical challenges, successes and failures, glove-wearing, time-pressed medics to use. which are being evaluated in full. MSF Ebola is not over until there are zero The tablet allows staff to access a patient’s already considers, as an initial lesson, cases in the region for a period of 42 history and collect more complete health that we should have mobilised more days. Perseverance and tenacity are data – such as pulse and respiration rates – to better track a patient’s progress and human resources earlier across the mandatory for the medical teams, while provide them with individually tailored care. entire movement. gaining the trust and positive collab- oration of the affected communities. © Ivan Gayton/MSF©

|20 Meanwhile a practical plan to sustain in the capitals. But beyond having the “The Ebola outbreak has been often research and development for vac- means, political will is crucial to put this described as a perfect storm: a cross- cines, treatments and diagnostic tools knowledge into practice. border epidemic in countries with must be developed. These will be key weak public health systems that had in protecting the region from current or More aid organisations have now been never seen Ebola before,” says Chris- future resurgences of similar outbreaks. trained on Ebola management by MSF, topher Stokes. “Yet this is too con- the WHO and CDC. The knowledge has venient an explanation. For the Ebola Rebooting health services in been shared, but it risks being of little outbreak to spiral this far out of con- Guinea, Sierra Leone and Liberia use if it is not immediately deployed at trol required many institutions to fail. The trauma of Ebola has left people the onset of another epidemic. And they did, with tragic and avoidable distrustful of health facilities, has left consequences.” health workers demoralised and fearful “The flexibility and agility for a fast, of resuming services, and has left com- hands-on emergency response still munities bereaved, impoverished and does not sufficiently exist in the global suspicious. health and aid systems,” says Dr Liu. “Lessons that should have been learned Nearly 500 healthcare workers have lost in the mass cholera epidemic in their lives in this epidemic, a disastrous four years ago were not.” blow to an already serious shortfall of staff in the three countries before the Though the WHO Executive Board has Ebola crisis hit. passed a resolution to enact reforms for epidemic response and address The basic relaunching of health services internal incoherence, it seems unlikely is urgent. Children have missed vac- that radical reform will happen over- cinations, HIV patients have had their night. Realistically, few member states treatment interrupted and pregnant have any interest in empowering an women need a safe place to deliver their outside international body to respond babies. to epidemics in their territories. How- ever, it is clear that member states However, restoring healthcare systems must engage more swiftly and strongly to pre-Ebola levels without addressing to support those countries that lack the the underlying flaws and weaknesses is capacity to respond to infectious dis- not enough. Improving access to health- ease outbreaks. care, and improving the quality of ser- vices on offer, will be necessary to allow But let us avoid jumping to convenient early detection of any future outbreaks conclusions. It would be a mistake to of Ebola and other infectious diseases, attribute full responsibility for the dys- as well as a more effective response. functional response to just one agency. It is unreasonable to expect different Instead, the age-old failures of the results when applying similar strate- humanitarian aid system have also been gies and approaches. laid bare for the world to see, rather than buried in underreported crises like The risk that lessons won’t be those in Central African Republic and learnt South Sudan. After every large-scale humanitarian emergency, there is the hope that les- Global failures have been brutally sons from it will be learned. However, exposed in this epidemic and thousands this feel-good rhetoric is often not of people have paid for it with their lives. enough. The world is more interconnected today than ever before and world leaders “For months, ill-equipped national cannot turn their backs on health crises health authorities and volunteers from in the hope that they remain confined a few private aid organisations bore the to poor countries far away. It is to eve- brunt of care in this epidemic. There is ryone’s benefit that lessons be learned something profoundly wrong with that,” from this outbreak, from the weakness says Dr Liu. of health systems in developing coun- tries, to the paralysis and sluggishness Health authorities in Guinea, Liberia of international aid. and Sierra Leone now possess the kno- whow to detect, investigate and tackle Ebola, while laboratories are in place 21| Map of the region

GUINEA

• DABOLA • TÉLIMÉLÉ • BOFFA • KANKAN • FARANAH CONAKRY • • FORÉCARIAH • KISSIDOUGOU • KAMBIA • KÉROUANÉ • MACENTA MAGBURAKA • FREETOWN • KAILAHUN • • GUÉCKÉDOU SIERRA • FOYA LEONE • BO

LEGEND

Activities set up and run by MSF • GRAND CAPE MOUNT over the course of the last year:

Ebola management centre • BOMI • QUEWEIN MONROVIA • Transit centre LIBERIA

Training facility • RIVER CESS

Clinical trial site

Rapid response team

www.msf.org